1. For Office Use only
URN …………………….
HEALTH FORM
A completed form must be submitted for every camper (young persons and leaders) attending. This will be held by the
Medical / First Aid Centre in case of accident / illness and the information will be treated as confidential. If there are any
subsequent changes to the details given below, these must be notified to the Camp Administration, in writing (by parent /
guardian if camper is under 18 years old), prior to the camper’s arrival on site.
Please complete in ball-point pen in block capitals, delete starred (*) items as appropriate.
Troop / Unit Name:…………………………..……………………………………………………………………………………………….
Troop SwEng Dutch
Surname / Family Name: …………………………………………. First Names: …………………..……………………………………..
Date of Birth: ……………..……………………………………… National Health Number: …………………………………………….
In an emergency you should contact the following person:
Surname /Family Name: ……………………………………… First Names:…………………………………………………..
Relationship to camper:……………………………………….
Address:………………………………………………………………………………………………………………………….
………………………………………………………………………………………………. Post/Zip Code ………………….
Tel: (Daytime) …………………………………………………
(Evening) ………………………………………………..
(Mobile) …………………………………………………
Own / Family Doctor: (Name) …………………………………………………………………………………………………………….
Address ……………………………………………………… …………………………………………………………………………..
Telephone Number: ………………………………………………………………………………………………………………………
Details of any disabilities, conditions, allergies, special needs or cultural needs that might affect this
event:
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………

2. Details of any medications currently being taken:
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
……………………………………………………………………………………………………………….
………………………………………………………………………………………………………………
……………………………………………………………………………………………………………….
………………………………………………………………………………………………………………
Details of any infectious diseases he/she/I has been in contact with in the last 3 weeks
………………………………………………………..………………………………………………………..
………………………………………………………..………………………………………………………..
………………………………………………………..………………………………………………………..
………………………………………………………..………………………………………………………..
………………………………………………………..………………………………………………………..
………………………………………………………..………………………………………………………..
Continue on a separate sheet and attach if necessary
If it becomes necessary for the above named young person / adult to receive medical treatment and I cannot
be contacted to authorise this, I hereby give my general consent to any necessary medical treatment and
authorise the leader in charge to sign any document required by the hospital authorities.
Signed …………………………………………………………………………..
Relationship to young person …………………………………………………..
Signed (if over 18) ……………………………………………………………..
Date ……………………………………………………………………………..
Note: The medical profession takes the view that the parent’s/carers consent to medical treatment cannot be delegated. The view is
explicit in The Children’s Act 1989. Thus, medical consent forms have no legal status and a doctor or nurse insisting on the consent
of a parent/carer to a particular treatment has the right to do so. For this reason we do not recommend that leaders insist on parents
/carers signing the statement above. However, it can be a comfort to medical staff to have a general consent in advance from
parents/carers or to have a leader on hand able to sign forms required by medical authorities.